Formulary guidance and transparency from P&T to point of care

Radar On Market Access: Centene, UnitedHealth Ring in New Year With M&A

Posted by Leslie Small on Jan 14, 2021

Although 2021 has just begun, major health insurers appear to be wasting no time when it comes to spending the influx of cash that they've collected as a result of lower routine health care utilization during the COVID-19 pandemic, AIS Health reported.

On Jan. 4, Centene Corp. revealed that it struck a deal to purchase Magellan Health, Inc. for $2.2 billion, a transaction that promises to augment the insurer's existing behavioral health, specialty health care and pharmacy management assets. Two days later, UnitedHealth Group said it plans to purchase the technology company Change Healthcare for approximately $13 billion in a deal that will bolster its analytics and advisory arm, OptumInsight.

Read More

Topics: Industry Trends, Payer

Radar On Market Access: FDA Approves First Oral Treatment for HAE Attack Prevention

Posted by Angela Maas on Jan 12, 2021

When the FDA approved BioCryst Pharmaceuticals, Inc.'s Orladeyo (berotralstat) last month, the drug became the first oral treatment for prophylaxis to prevent hereditary angioedema (HAE) attacks, AIS Health reported. According to Zitter Insights, payers with nearly three-quarters of covered lives plan to manage it at parity to other prophylactic treatments.

The FDA approved the first drug to treat HAE, Shire plc's Cinryze (C1 esterase inhibitor [human]), on Oct. 10, 2008. Since then, the FDA has approved eight drugs to treat HAE: half for acute attacks and half for prophylaxis.

Read More

Topics: Industry Trends, Market Access, Product Release

Perspectives on New-to-Market Oral Drugs

Posted by Leslie Small on Jan 7, 2021

In its latest quarterly Drug Pipeline Insights Report, OptumRx includes a diverse array of medications that the UnitedHealth Group-owned PBM believes are likely to make a market impact when they're approved by the FDA, AIS Health reported. One interesting trend that applies to three of the five highlighted drugs is the fact that each is the first oral option in its respective category.

While oral medications tend to be thought of as more convenient than injectable or IV-administered therapies, that factor alone may not confer as much of a competitive advantage as one might think, according to one OptumRx executive.
Read More

Topics: Industry Trends, Product Release, Data & Analytics

Radar On Market Access: Supreme Court's ACA Ruling May Upend Biosimilars Market

Posted by Angela Maas on Jan 7, 2021

As the Supreme Court decides on the fate of the Affordable Care Act (ACA), much of the focus has been on the people who would lose health insurance coverage and protections for pre-existing conditions if the law is overturned. Another ramification of such a ruling is that the biosimilars market could be completely upended, AIS Health reported.

The Biologics Price Competition and Innovation Act of 2009 (BPCIA) created the 351(k) biosimilar pathway. After more than one attempt to get a stand-alone bill to pass, lawmakers made it part of the ACA, and it became law on March 23, 2010.

Read More

Topics: Industry Trends, Market Access, Payer

Radar On Market Access: Despite New Approvals, Plans Still Favor Generics for Epilepsy

Posted by Jane Anderson on Jan 5, 2021

Pharmaceutical treatment for different types of epilepsy generally still relies on tried-and-true generics, despite recent efforts by drug manufacturers to introduce new branded medications into the mix, PBM insiders tell AIS Health.

Xcopri (cenobamate tablets), manufactured by SK Biopharmaceuticals Co., Ltd.'s subsidiary SK Life Science, Inc., launched in May for the treatment of partial-onset seizures. However, many plans haven't jumped to add Xcopri to their formularies, says Mesfin Tegenu, R.Ph., president of PerformRx.

Read More

Topics: Industry Trends, Market Access, Product Release

Radar On Market Access: Surprise Medical Billing Comes to An End, Insurers Oppose Arbitration Mechanism

Posted by Peter Johnson on Dec 31, 2020

After years of failed attempts, Congress has finally come to an agreement on a measure to end the practice of surprise medical billing, AIS Health reported.

Surprise billing, also known as balance billing, is the practice of charging patients for out-of-network procedures that insurers refuse to pay for in whole or in part. Often, patients incur these balance bills without their knowledge. The new legislation would ban providers from sending such a bill to patients, and would instead require providers to negotiate reimbursement with the patient's insurer or submit the dispute to a binding arbitration process.

Read More

Topics: Industry Trends, Payer

Radar On Market Access: PBMs Continue Integration, Face More Regulatory Challenges in 2020

Posted by Peter Johnson on Dec 29, 2020

In 2020, the PBM industry continued to deepen its integration with other industry players, a trend that experts say is likely to continue in coming years. The PBM space has consolidated to the point that five firms — UnitedHealth Group's OptumRx, CVS Health Corp.'s Caremark, Cigna Corp.'s Express Scripts, Anthem Inc.'s IngenioRx, Humana Inc.'s Humana Pharmacy Solutions, and the Blue Cross and Blue Shield affiliate-owned Prime Therapeutics LLC — manage the lion's share of the pharmacy benefits offered to U.S. health plan members.

Beyond their deepening integration with the payers that own them, these firms are working to expand their data and direct-to-consumer operations, AIS Health reported.

Read More

Topics: Industry Trends, Market Access, Data & Analytics, Payer

Perspectives on Amazon Pharmacy

Posted by Leslie Small on Dec 24, 2020, Inc. made a splash in the health care world on Nov. 17 when the online retail powerhouse unveiled new pharmacy offerings that aim to disrupt the prescription drug market with increased convenience and savings, AIS Health reported.

In addition to setting up its own online pharmacy, Amazon is partnering with one of the three largest PBMs — Cigna Corp.'s Express Scripts — to offer a prescription-savings benefit that will be available to Amazon Prime members. "It can be used for discounts up to 80% off generic and 40% off brand name medications at over 50,000 participating pharmacies nationwide," according to a press release.
Read More

Topics: Industry Trends, Data & Analytics, Payer

Radar On Market Access: MCO Messaging Plays Key Role in COVID Vaccine Rollout

Posted by Lauren Flynn Kelly on Dec 24, 2020

States and the federal government recently began rolling out the COVID-19 vaccine to health care workers across the country. Health plans, particularly those that serve high-risk individuals, may be ideally situated to coordinate care and update members on vaccination opportunities, experts tell AIS Health.

The FDA on Dec. 11 authorized emergency use of the COVID-19 vaccine made by Pfizer Inc. and BioNTech in individuals age 16 and older. Then the agency on Dec. 18 authorized Moderna’s vaccine for emergency use in people 18 years or older.

Read More

Topics: Industry Trends, Market Access, Product Release, Payer

Radar On Market Access: Biden Probably Won't Roll Back New Prior Authorization Proposal

Posted by Leslie Small on Dec 22, 2020

Building on previously finalized regulations aimed at advancing data interoperability in health care, CMS on Dec. 10 proposed a new rule that would require certain health plans to make their prior authorization processes more efficient and share even more data with providers and patients, AIS Health reported.

If finalized, the rule would apply only to managed care Medicaid and CHIP plans, fee-for-service Medicaid and CHIP plans, and Qualified Health Plans (QHPs) on the federally facilitated exchanges.

Read More

Topics: Industry Trends, Payer